HEALTH SYSTEM TRANSFORMATION IN MYANMAR: ARE THE

Transcription

1 HEALTH SYSTEM TRANSFORMATION IN MYANMAR: ARE THE CURRENT CHANGES PROMISING? Phyu Phyu Thin Zaw, MBBS, PhD VisiHng Scholar/WHO- HRP Career Development Fellow Asia Health Policy Program Shorenstein- APARC 1 5/26/2015

2 Myanmar profile Myanmar s current health status Myanmar Health System Overview Comparison with South East Asian countries Equity of access to ReproducBve Health services Current Changes in Myanmar Health System Conclusions and RecommendaBons 2

3 AdministraHve Division 7 Regions 7 States Area :Slightly smaller than the U.S. state of Texas. Neighbors : China, India, Thailand, Bangladesh and Laos 3 Once South East Asia s wealthiest nabon PoliHcs Was the second most isolated country next to North Korea from 1962 to 2012 In a transibonal period amer 63 years of military regime Increased transparency More freedom of speech, moderate media freedom Some posibve approaches (Ref: 2014 census, WHO 2011)

4 Beautiful Myanmar" Ethnicity Over 130 ethnic groups with 8 major groups Internal Conflicts: One of the longest civil wars Abundant natural resources: 2nd lowest Human Development Index in Asia Pacific Region

5 Beautiful Myanmar! PHOTO CREDIT

6 World Bank, 2013 Wikipedia contributor 2013

7 1. Life Expectancy 2. Maternal Mortality 3. Infant Mortality 4. Prevalence of Communicable Diseases (HIV/ TB/Malaria) 5. Prevalence of Non- communicable diseases 7

8 8 Life expectancy in Myanmar Male: 63.4 Female: 67.1 Total: 65.2

9 " 200 per 100,000 live births " Three quarters of all maternal deaths occur: " Delivery " Immediate post- partum period " Low access to essenbal maternal health services 9 Maternal Mortality RaHos and Percentage of Skilled Birth AZendant in SEAR

10 10 " IMR: 48 nabonally; 94.2 in the east " Under Five Mortality Rate: " 62 nabonally " in the east " Highest in Southeast Asia UNICEF report 2013

11 11 Source: Ministry of Health, Myanmar

12 High burden of CD: tuberculosis (TB), malaria and HIV/AIDS Top three nabonal priority diseases of Myanmar (MOH, 2013) 12 Global Tuberculosis report WHO- 2013; Beyrer 2006

13 13 Number of youths living with HIV

14 Five Risk Factors 1. Dietary risks 2. Tobacco smoking 3. Household air pollubon from solid fuels 4. High blood pressure 5. High fasbng plasma blood sugar (IHME, 2010) 14 Source: World Health OrganizaHon - Noncommunicable Diseases (NCD) Country Profiles, 2014.

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16 The first major reform to achieve UHC (Health for All)" After independence: Health System was temporarily interrupted" Military Regime" Democratization Period" Colonial Period: British Health System" " Lack of government investment in healthcare " RestricBon of NGO provision of health services EradicaBon of smallpox 1977 EliminaBon of leprosy, trachoma, poliomyelibs, and iodine- deficiency disorders

17 A pluralisbc mix of public and private systems both in financing and provision 17 The WHO Health Systems Framework

18 Department of health professional Resource development and management Department of Medical Care Deputy Minister Union Minister for Health Permanent Secretary Office Department of Public Health Department of Medical Research Deputy Minister Department of FDA Department of TradiBonal Medicine 18 UN Agencies, Bilateral, INGOs, NaHonal Health Policy NaHonal Health Plan Myanmar Health Vision 2030 Rural Health Development Plan Other Ministries NaHonal NGOs, Private Sector

19 The government used to be the main source of financing Private out- of- pocket (OOP) payment became the main source of finance: cost sharing in 1993 Total health expenditure in Myanmar: % of its GDP between The lowest among countries in the World Health OrganizaBon Donor contribuhons remain substanbal, at 7% of total health expenditure in 2011 (half what the government spends on health). 19 Source: Asia Pacific Observatory on Health Systems and Policies

20 100.0% 75.0% 50.0% GGHE as % of THE PrivHE as % of THE 25.0% 0.0% Source: Department of Health Planning, Ministry of Health, Myanmar

21 21 % of total health expenditure

22 % of GDP

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24 Nearly 100% of private health expenditure ( ) Over 30% of households encountered catastrophic health expenditure (MOH & UNICEF unpublished informabon, 2012) % of total health expenditure 24 Out- of- pocket Health Expenditure in SEAR ( )

25 No health insurance system at all in Myanmar Social security system : established in 1956 For insured workers who are employed in the private sector For enterprises having more than five employees Benefits : free medical care during illness, payment of 75% of basic salary during maternity leave, full salary for one year for severe injuries, cash payments for death and injury, and survivors pension The scheme covers less than 1% of the populahon 25 Source: Asia Pacific Observatory on Health Systems and Policies

26 The Department of Medical Science : doctors, nurses and health care workers Density of physicians: per 1000 populabon It was sbll far below the global standard of 2.28 health workers per 1000 populabon UnderproducHon of dental surgeons, pharmacists and technicians as compared to doctors and nurses. Limited registrahon for foreign doctors to work in Myanmar 26 Source: Ministry of Health, Myanmar, unpublished data

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28 28 Source: Asia Pacific Observatory on Health Systems and Policies

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30 Looking at the distribubon of health care facilibes and beds across the country, inequibes are evident. A discrepancy index lower than 1.0 means that a region or state has fewer beds per 1000 populabon than the nabonal average (1.0). 30 ScaZer plot showing discrepancy index of hospital beds and hospital uhlizahon

31 EssenHal Medicine List The Myanmar EssenBal Drugs Programme has revised the NaBonal List of EssenBal Medicines The Central Medical Store Depot (CMSD) procured a subset of 92 medicines from the essenbal medicine list in 2010 The Ministry of Finance did not provide enough funds to procure all the needed essenbal medicine (Holloway, 2011) Ministry of Health, Myanmar, unpublished data 31

32 General radiography (e.g. X- ray machines) represents as most basic equipment available at township and stabon hospitals across the country. Computed tomography (CT) was only available in Yangon and Mandalay General Hospitals unbl Five magnebc resonance imaging (MRI) scanners are operated in big cibes. There is a need to strengthen regular maintenance mechanism of medical devices. 32 Source: Asia Pacific Observatory on Health Systems and Policies

33 Comprises hospital informabon, public- health informabon, human- resources informabon and logisbcal informabon Data are collected manually by individual using standardized forms DisseminaBon of stabsbcs : an annual public health stahshcs report Due to lack of adequate resources and capacity, populabon- based surveys could not be carried out as frequently as needed 33 Source: Asia Pacific Observatory on Health Systems and Policies

34 Information Technology Trends in Internet Users in Government Sector and General Public

35 Rural Area Village Volunteers or Midwifes" Traditional Medicine" Rural Health Center" Station Hospital" Patient" Urban Health Center" Township Hospital" Public Tertiary Hospital" Small clinics run by GPs" District Hospital" Private Tertiary Hospital" 35 Urban Area Traditional Medicine Clinics" PRIMARY CARE Private Hospital" SECONDARY CARE TERTIARY CARE

36 Second worst in terms of overall health system performance by the WHO in 2000 OOP payment is the highest in the world, at 81% of total health expenditures EsBmated three- quarters of Myanmar s cibzens find themselves with very limited access to essenbal health services World Bank (2012) 36

37 Equity of Access to ReproducHve Health Services Among Youths in Poor CommuniHes of Mandalay City Phyu Phyu Thin Zaw, Tippawan Liabsueltrakul, Edward McNeil, Thein Thein Htay BMC Health Serv Res Dec 15;12:458. doi: /

38 India China Thailand Mandalay city " PopulaBon: nearly 1 million " EsBmated 10 resource- limited suburban communibes " 50,000 living in resource- limited suburban communibes Map of Myanmar

39 Map of Mandalay city" Study Design Community- based cross- secbonal study Part I :QuanBtaBve methods Part II: QualitaBve methods " Formal sezlements " Riverbank sezlements " Polakee sezlements Study seing All resource- limited suburban communibes in Mandalay city

40 Data collechon at one of the Polakee CommuniHes

41 I really want to go to school." During data collechon at one of the Polakee CommuniHes

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43 Geographical accessibility (79%) Financial accessibility (19%) Overall, only 34% were able to access at least one RH service centre within 30 minutes walk at an affordable cost and were aware that the service existed. Factor Adjusted OR (95% CI) P-value* Youth's place of residence: ref.= Formal Settlements < Polakee Settlements Riverbank Settlements 0.36 ( ) 0.29 ( ) LogisBc regression analysis adjusbng all confounding factors OR: Odds RaBo; CI:Confidence Interval

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45 Significant increase in health expenditures, which raise the share of GDP allocated to health From 2.4% in 2012 to 3.14% in 2013 and 3.82% in 2015 Nine fold increase from 2011 to 2015 Share of Public Health Expenditure in Total Health Expenditure from 20% to 34% Focus on medicines, medical equipment, and building infrastructure for health insurance Level of health investment is sbll low compared to the demand for health care SBll the lowest compared to other countries in SEAR 45

46 Department of Health s State and Region Budget AllocaHon Source: Department of Health Planning, Ministry of Health, Myanmar Kachin Kayah Karen Chin Sagaing Tanintharyi Bago Magway Mandalay Nay Pyi Taw Mon Rakhaing Yangon Shan (S) Shan (N) Shan (East) Ayeyarwaddy

47 47 " The Social Security Law (August 2012) " Full medical reimbursement for every civil servant (Civil Servant Medical Benefit Scheme) in 2016 " Expansion of payroll tax financed social health insurance for formal sector (private and civil servant) " Development of new social protection policy (2014) to provide health and social benefit for informal sectors " Stakeholders meetings for development of feasible private health insurance for affordable population Department of Health Planning, MOH"

48 Three mechanism to cover this informal sector: Full contribubons by members (the Philippines) ParBally subsidized by the Government either central or local (Vietnam, China) Covered by tax financed scheme (Thailand) 48

49 Human Resources for Health Master Plan: prepared in 2012 for the next years AppoinHng new health care workers: Many professionals graduated, but were not employed by the government. Over registered medical doctors: about were employed by public agencies Increased salary: Doctors (from 150 US$ to 250 US$) Expansion of hospitals and beds provision 30 CT scanners by the end of 2013: available in the general hospitals of all region and state Hospitals. Supplied essenhal drugs to the hospitals (Quick- Win approaches) 49 (MOH, 2013)

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51 CollaboraBon with various actors in Health Sector since 2011 The Three Millennium Development Goals (3MDG) Fund started in 2013 Many other internabonal nongovernmental organizabons INGOs (e.g. PATH, MSI, Save the Children, World Vision, Oxfam, Medecins Sans FronBeres, AMDA, ADRA, CARE InternaBonal, Burnet InsBtute, Merlyn, Malteser) Working separately to finance specific health- development programmes 51

52 " Health-care systems are diverse in SEAR" " Range from dominant tax-based financing to social insurance and high Out-of-pocket OOP payments" " Government spending is generally low in ASEAN, except Thailand and Brunei" " Singapore s health system is the best based on international assessments" " Thailand s Universal Health Coverage: the most successful story reaching the poor (98% coverage)" " Increased government health spending: the more significant gains" Source: Stephan Lock, Global PracBces, 2013

53 Myanmar is facing a very important transihonal period 82% of total health spending in Myanmar is out- of- pocket, the highest in the world The recent increase in government spending for health is encouraging; however it is not sufficient Social ProtecHon System is in the developmental stage Financial- risk protechon for the majority of the populabon who are poor and from informal sectors is sbll lacking 53

54 Human resources for health are constrained Job sahsfachon among health care provider is unsabsfactory InequiHes in distribuhon of the health workforce, parbcularly at the most peripheral level of the system Very weak health informahon system A large influx of internahonal development partners and donor funding 54

55 1. Equity of access to health care: of vital importance 2. Government commitment: more investment in health 3. InternaHonal aid: adhere to the Paris DeclaraBon on Aid EffecBveness 4. The country s future healthcare advancements will most likely stem from the private sector: appropriate policies should be considered 5. No major evaluahon or impact study has been carried out so far specifically linked to these reforms and such studies are strongly suggested 55

56 1. Asian Development Bank (ADB) (1996). Country synthesis of post evaluabon finding in Myanmar. Manila: ADB Post EvaluaBon Office. 2. Asian Development Bank (ADB) (2012). Myanmar in transibon: opportunibes and challenges.22 February Central StaBsBcal OrganizaBon (CSO) (2009). StaBsBcal year book Nay Pyi Taw: CSO, Ministry of NaBonal Planning and Economic Development. 4. Central StaBsBcal OrganizaBon (CSO) (2012). StaBsBcal year book Nay Pyi Taw: CSO, Ministry of NaBonal Planning and Economic Development. 5. Department of Health NaBonal Tuberculosis Programme (DOH- NTP) (2011). The five- year NaBonal Strategic Plan (NSP) ( ). Nay Pyi Taw: DOH. 6. Health System in TransiBon, The Republic of Union of Myanmar, Health System Review, Asia Health Observatory on Health Systems and Policies 7. World Health OrganizaBon (WHO) (2000). The world health report Health systems: improving performance. Geneva: WHO (hsp:// accessed 26 November 2013]. 8. Handler A, Issel M, Turnock B. A Conceptual Framework to Measure Performance of the Public Health System. American Journal of Public Health. 2001;91(8): Dhillon PK, Jeemon P, Arora NK, et al. Status of epidemiology in the WHO South- East Asia region: burden of disease, determinants of health and epidemiological research, workforce and training capacity. InternaNonal Journal of Epidemiology ;41(3): doi: /ije/dys046.

57 Prof. Karen Eggleston and all the members of APARC WHO- HRP for the financial support DMR- UM and Ministry of Health (Myanmar) My research team as well as all the poor and marginalized groups from Myanmar 57

58 THANK YOU! Welcome to Myanmar, the Golden Land!"